Valvular Heart Disease

Hakim Alkatiri

Mitral Stenosis

Mitral Stenosis

Causes •rheumatic fever•congenital abnormality, calcification, myxoma

Natural history•RF age 12•murmur 1st heard 20 yrs later•symptoms in 3-4th decade

Mitral Stenosis - Clinical features Severity MVA (cm²) LAP (mm Hg) CO

Mild >2.0 <10-12 NL

Moderate 1.1-2.0 ~10-17 NL

Severe <1.0 >18

Very Severe <0.8 >20-25

Severity Symptoms

Mild Asymptomatic or mild DOE

Moderate Mild-mod DOE; orthopnea, PND, hemoptysis

Severe Dyspnea at rest; possible pulmonary edema

Very Severe Severe PHT; RV failure, marked dyspnea at rest;severe fatigue; cyanosis

Mitral Stenosis - Examination

InspectionMalar flushPeripheral cyanosis (severe MS)Jugular venous distension (right ventricular failure)

PalpationParasternal right ventricular impulsePalpable pulmonary arterial impulsePalpable S1, P2, and occasionally, the diastolic rumble

AuscultationIncreased intensity of the first heart soundOpening snapLow-pitched diastolic rumbling murmur

Mitral Stenosis - Treatment

Medical

•Diuretic - pulmonary congestion

•Prevent embolism - cause of 19% deaths, with LA size and age

anticoagulate all with PAF/AF, SR in older age

•Control atrial fibrillation

Mitral Stenosis - Treatment

Balloon Mitral Valvuloplasty

Mitral Stenosis - Treatment

Balloon Mitral Valvuloplasty

•100% MVA, final area ~2cm2

•Failure rate 1-15%

•Mortality 0-3%

•Severe MR 2-10%

•Restenosis ~40% at 7years

•Contraindications - thrombus, MR, Ca++, other disease

Mitral Stenosis - Treatment

Mitral Valve Replacement

•Open mitral valvotomy

•Mitral valve replacement

Mitral Regurgitation - Aetiology

•Primary

Annulus annular calcification

Leaflet myxomatous degeneration

rheumatic deformity

infectious perforation

Chordae myxomatous degeneration

spontaneous rupture

rheumatic shortening

infectious destruction

Papillary infarction

ischemic lengthening•Functional

LV dilatation and PM displacement

CXR

Mitral Regurgitation - Pathophysiology

Mitral Regurgitation - Clinical findings

Acute dyspnoea, orthopnoea

no cardiomegaly, short murmur, S3

Chronic variable symptoms

cardiomegaly, murmur, P2 loud, S3

Quantification

•echocardiography, angiography

•serial studies, LV function

Mitral Regurgitation - Outcome in Chronic MR

Variable course - diagnosis to symptoms 16 years

Symptomatic severe - survival 33% at 5 years

mortality ~5% per year

LV dysfunction most important factor

Mitral Regurgitation - Treatment

•Diuretics LV filling P, p oedema

•Vasodilators forward SV

•IABP

Acute

Chronic

No known effective therapy

•Vasodilators - theoretical risks

•Treat complications

Mitral Regurgitation - Surgery

Options

•Valve repair

•MVR with chordal preservation

•MVR with destruction MV apparatus

Outcome

•Mortality 80-94% v 40-60% at 5-10years

•Valve function

•Ventricular function

Mitral Regurgitation - Indications for surgery

No randomised trials!!

1. Symptomatic with normal LV function

•prognosis worse once NYHA class II symptoms

2. Symptomatic with abnormal LV function

• If severe LV impairment - poor outlook

•EF < 30% ?medical Rx better

Mitral Regurgitation - Indications for surgery

3. Asymptomatic with abnormal LV function

• ? Asymptomatic

•Detection of LV dysfunction is the key

EF<60%, LVESD > 45mm, LVESV>55ml/m2

4. Asymptomatic with normal LV function

•?guaranteed repair

•PHT, recent AF

Mitral Regurgitation - Indications for surgery

Mitral Regurgitation - Prolapse

•2-4% population

•females:males 2:1

•diagnosis from echocardiography

•subcategory according to leaflet abnormality

•SBE prophylaxis; normal + MR or abnormal leaflets

Aortic Stenosis - Aetiology

•Congenital 1st-3rd decade

Valve degeneration and calcification

•Rheumatic - 4th decade

•Bicuspid valve; 1%, males>females, 5-6th decades

•Tricuspid valve - 7-8th decades, 1-2% incidence

Aortic Stenosis - Pathophysiology

LV pressure overload LV hypertrophy diastolic LV dysfunction

Systolic function usually preserved except late in disease

Systolic function improves with AVR

Outcome is dependent on symptoms

Aortic Stenosis - Clinical features

Symptoms

•None

•DOE, dizziness

•HF, syncope, angina

Examination

•Pulse - amplitude, delay

•Sustained apex

•S2- soft and single paradoxical splitting

•ESM - loud late peak soft

Aortic Stenosis - Severity

Echocardiography

Meangradient(mmHg)

Peak Aovelocity

AVA(cm2)

Normal 1.0-2.0 >2.5

Mild <20 2.5-2.9 >1.7

Moderate 20-40 3.0-4.0 1.0-1.7

Severe >40 >4.0 <1.0

Aortic Stenosis - Outcome

Symptoms

•2-year survival < 50%

Asymptomatic

•Generally good prognosis

•Peak velocity >4.0m/s 2yr event-free survival 21%

•Progression of> 0.3m/s per year - worse

Aortic Stenosis - Treatment

Medical

•None!!!

•Diuretics v LVF

•ACEI contraindicated

Balloon aortic valvuloplasty

•Average MVA improvement 0.8cm2 1.0cm2

•Restenosis <6/12 in 50%

•No improvement in mortality

•Procedural mortality 5%

Aortic Stenosis - AVR

Indicated only if symptomatic

•Mortality 0.6-5%

•Survival 67-85% at 5 yrs, 70% at 10yrs

•2yr survival 4x greater than medical treatment

LV dysfunction

•?impairment from pressure overload or other cause

•DSE may be helpful

Aortic Stenosis - AVR

Aortic Regurgitation - Aetiology

Root

Annuloaoroectasia

Marfans

Dissection

Syphillis

Ankylosing spondylitis

Leaflet

Endocarditis

Bicuspid valve

Rheumatic heart disease

Aortic Regurgitation - Pathophysiology

Normal

Acute Aortic Regurgitation - Clinical features

No time for LV to enlarge

total SV, fwd SV, LVEDP

Quiet S1 (presystolic MV closure), short murmur

Treatment

•Medical therapy ineffective

•AVR if symptoms/signs LVF

Chronic Aortic Regurgitation - Clinical features

total SV, maintained fwd SV, RV runoff in diastole systolic BP, diastolic BP

Volume and pressure overload

Examination - hyperdynamic circulation, wide pulse pressure, dilated LV, EDM duration important

Chronic Aortic Regurgitation - Clinical features

Maybe asymptomatic, LVF, angina

LV decompensation

Chronic Aortic Regurgitation - Treatment

Medical - afterload

Nifedipine 20mg bd delayed surgery by 2-3 yrs

Duplicated with small ACEI trials

Vasodilator therapy

ACC / AHA Practice Guidelines 2006Indications for AVr/R

Class I1. AVR is indicated for Symptomatic patients with

severe AR irrespective of LV systolic function. 2. AVR is indicated for asymptomatic patients with

chronic severe AR and LV systolic dysfunction ( EF 50 % or less) at rest.

3 AVR is indicated for patiens with chronic severe AR while undergoing CABG or surgery on the aorta or other heart valves.

ACC / AHA Practice Guidelines 2006Indications for AVr/R

Class I1. AVR is indicated for Symptomatic patients with

severe AR irrespective of LV systolic function. 2. AVR is indicated for asymptomatic patients with

chronic severe AR and LV systolic dysfunction ( EF 50 % or less) at rest.

3 AVR is indicated for patiens with chronic severe AR while undergoing CABG or surgery on the aorta or other heart valves.

SummaryDiagnosis Auscultation Other P. E Radiograph ECG Therapy

- S1 loud diureticMirtal - Opening snap - ↑LA, PA, RV - RAD, LAE anti coagulanstenosis present followed RV lift - Normal LV - (±) RVH

by a mid-diastolic BMVrumble surgery- Holosystolic LV heave ↑ LA and LV - LAE diuretic

Mitral Regur- usually radiating - AF vasodilatorgitation to the axilla common

- S1 soft, S3 surgerycommon

Aortic - Ejection type - LVH none !!stenosis early systolic May have a - Aortic (medical)(transmitted murmur thrill at the valve LAD and BAVfrom base) - Also heard at right 2nd ICS calcification LVH surgery

right 2nd ICS withradiation to thecarotids

Aortic diastolicregurgitation murmur at left - RV lift Hypovascular vasodilator

base - Peripheral lung fields if - RAD surgery- P2 loud if PR signs or AR pulmonary - RVHsecondary to absent hypertensionpulmonary presenthypertension

SummaryDiagnosis Auscultation Other P. E Radiograph ECG Therapy

- S1 loudTricuspid - Mid-diastolicstenosis rumble ↑ a waves ↑ RA and SVC RAE

- increased by in JVPinspirationHolosystolic - ↑ V waves

Tricuspid murmur increases in JVP ↑ RA, ↑RV,regurgitation with inspiration - Pulsating ↑ SVC RAD

(Carvallo's sign) liver- RV failure

Ejection sistolic - RVHPulmonary with click ↑ A wave in - Poststenotic - RVHstenosis - S2 split, P2 soft JVP dilatation of -RAD

or absent PADiastolic

Pulmonary murmur at left - RV lift hypovascularregurgitation base - Peripheral lung fields if - RAD

- P2 loud if PR signs og AR pulmonary - RVHsecondary to absent hypertensionpulmonary presenthypertension